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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201268
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:08:00 PM

Document Has Been Signed on 04/30/2024 02:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:G & O RESIDENTIAL CARE, INCFACILITY NUMBER:
079201268
ADMINISTRATOR/
DIRECTOR:		GARCIA, OVILIO BARRIOSFACILITY TYPE:
735
ADDRESS:1550 LARKSPUR CTTELEPHONE:
(925) 565-5731
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 2DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:Ilianne Barandela Socarr CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 04/30/24 at 11:28AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Ilianne Barandela and explained the purpose of the visit. Ilianne Barandela contacted the Administrator via phone, LPA explained purpose of visit to Administrator. Administrator arrived at 1:02PM. The Administrator currently holds a certificate (#6061880735) expires 06/25/2025. Facility has census of 2. LPA observed two (2) clients during visit. The facility’s fire clearance was approved for two (2) ambulatory and 2 non ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of three (3) bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/09/2024. Emergency Disaster Plan was last posted on 02/20/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/12/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: G & O RESIDENTIAL CARE, INC
FACILITY NUMBER: 079201268
VISIT DATE: 04/30/2024
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Continued from LIC809.

Three (3) staff records were reviewed. LPA reviewed all Two (2) resident records, and they were current and complete. LPA reviewed samples of medication and P&I.


LPA requested the following documents to be submitted to CCLD by 05/08/2024.

· LIC 500 Personnel Report
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 610E Emergency Disaster Plan
· Liability Insurance

No deficiencies observed during visit


Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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